Surgically implantable knee prosthesis having medially shifted tibial surface

ABSTRACT

An implantable knee prosthesis includes a body having a substantially elliptical shape in plan and a pair of opposed faces. A peripheral edge of variable thickness extends between the faces and includes a first side, a second side opposite the first side, a first end and a second end opposite the first end. The thickness of the peripheral edge at the first side is greater than the thickness of the peripheral edge at the second side, the first end and the second end.

CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This is a continuation-in-part of application Ser. No.09/664,939, filed on Sep. 19, 2000, which is a continuation of Ser. No.09/297,943, filed May 10, 1999 and issued as U.S. Pat. No. 6,206,927

BACKGROUND

[0002] The present invention pertains to prosthetic devices. Moreparticularly, the invention pertains to knee joint prostheses which maybe surgically implanted between the femoral condyle and tibial plateauof the knee joint.

[0003] Articular cartilage and meniscal cartilage provide the mobileweight bearing surfaces of the knee joint. Damage to these surfaces isgenerally due to genetic predisposition, trauma, and/or aging. Theresult is usually the development of chondromalacia, thinning andsoftening of the articular cartilage, and degenerative tearing of themeniscal cartilage. Various methods of treatment are available to treatthese disease processes. Each option usually has specific indicationsand is accompanied by a list of benefits and deficiencies that may becompared to other options.

[0004] The healthy knee joint has a balanced amount of joint cartilageacross the four surfaces of this bi-compartmental joint (medial femoralcondyle, medial tibial plateau, lateral femoral condyle and lateraltibial plateau). In patients with osteoarthritis, degenerative processtypically leads to an asymmetric wear pattern that leaves onecompartment with significantly less articular cartilage covering thedistal portions (or weight bearing area) of the tibia and femur than theother compartment. Most commonly, the medial compartment of the kneejoint is affected more often than the lateral compartment.

[0005] As the disease progresses, large amounts of articular cartilageare worn away. Due to the asymmetric nature of the erosion, thealignment of the mechanical axis of rotation of the femur relative tothe tibia becomes tilted down towards the compartment which is sufferingthe majority of the erosion. The result is a Varus (bow-legged)deformity in the case of a medial compartment disease predominance, or aValgus (knock-kneed) deformity in the case of lateral compartmentdisease predominance. Factors such as excessive body weight, previoustraumatic injury, knee instability, the absence of the meniscus andgenetic predisposition, all affect the rate of the disease.

[0006] The disease is usually defined in stages of Grade I through V,with Grade III revealing significant articular cartilage loss, Grade IVrevealing some eburnation of the subchondral bone, and Grade V detailingboth significant articular loss and bone loss.

[0007] It is important to understand that the disease manifests itselfas periodic to continuous pain that can be quite uncomfortable for thepatient. The cause of this pain is subject to many opinions but it isapparent that, as the joint compartment collapses, the collateralligament on the side of the predominant disease becomes increasinglyslack (like one side of a pair of loose suspenders), and the tibial andfemoral axes move, for example, from a Varus to a Valgus condition. Thisincreases the stress on the opposing collateral ligament (and cruciateligaments as well) and shifts the load bearing function of thisbi-compartmental joint increasingly towards the diseased side. Thisincreasing joint laxity is suspected of causing some of the pain onefeels. In addition, as the bearing loads are shifted, the body respondsto the increased loading on the diseased compartment with an increasedproduction of bony surface area (osteophytes) in an attempt to reducethe ever-increasing areal unit loading. All of this shifting of the kneecomponent geometry causes a misalignment of the mechanical axis of thejoint. The misalignment causes an increase in the rate of degenerativechange to the diseased joint surfaces causing an ever-increasing amountof cartilage debris to build up in the joint, further causing jointinflammation and subsequent pain.

[0008] Currently, there is a void in options used to treat therelatively young patient with moderate to severe chondromalaciainvolving mainly one compartment of the knee. Current treatments includeNSAIDs, cortisone injections, hyaluronic acid (HA) injections andarthroscopic debridement. Some patients cannot tolerate or do not wantthe risk of potential side effects of NSAIDs. Repeated cortisoneinjections actually weaken articular cartilage after a long period oftime. HA has shown promising results but is only a short term solutionfor pain. Artliroscopic debridement alone frequently does not providelong lasting relief of symptoms. Unfortunately, the lack of long termsuccess of these treatments leads to more invasive treatment methods.Osteochondral allografts and microfracture techniques are indicated forsmall cartilage defects that are typically the result of trauma. Theseprocedures are not suitable for addressing large areas of degeneration.In addition, osteochondral allografts can only be used to addressdefects on the femoral condyle. Tibial degeneration can not be addressedwith this technique. High tibial osteotomy (HTO) corrects the varusmalalignment between the tibia and femur but, because it is performedbelow the joint line, it does not fill the cartilage void or re-tensionthe medial collateral ligament (MCL). Removing bone and changing thejoint line does not complicate the conversion to total knee arthroscopy(TKA). However, an HTO does leave a hard sclerotic region of bone whichis difficult to penetrate making conversion to a total knee replacement(TKR) technically challenging. Unicompartmental and bicompartmentaltotal knee replacements resect significant amounts of bone and, ifperformed on younger patients, will likely require revision surgery asthey age. Revision total knee replacement surgery is usually extensiveand results in predictably diminished mechanical life expectancy.Therefore, it is best to delay this type of bone resecting surgery aslong as possible.

[0009] The only true solution is to rebuild the defective joint by“filling” the joint space with more articular bearing material through acomplete resurfacing of the existing femoral condyle and tibial plateau.By replacing the original cartilage to its pre-diseased depth, the jointmechanical axis alignment is restored to its original condition.Unfortunately, these natural articular materials and surgical technologyrequired to accomplish this replacement task do not yet exist.

[0010] Currently, replacement of the existing surfaces, with materialsother than articular cartilage, is only possible with a total oruni-condylar knee replacement, and these procedures require removal ofsignificant amounts of the underlying bone structure.

[0011] The alternative method is to fill the joint space with a spacerthat replaces the missing articular materials. This spacer should alsoprovide an anatomically correct bearing surface for both the tibial andfemoral surface (U.S. Pat. No. 6,206,927).

[0012] Attaching a new bearing surface to the femoral condyle istechnically challenging and was first attempted, with limited success,over 40 years ago with the MGH (Massachusetts General Hospital) knee.Like a dental crown, it covered both femoral condyles with Vitallium(CoCr) and would bear against the existing tibial plateau.

[0013] Tibial covering devices such as the McKeever, Macintosh andTownley tibial tray, maintained the existing femoral surface as thebearing surface, but like the MGH knee, all required significant boneresection, thus making them less than ideal solutions as well.

[0014] These devices also made no particular attempt to match thepatient's specific femoral or tibial geometry thus reducing theirchances for optimal success. Because these devices were made of CoCr,which has different visco-elastic and wear properties from the naturalarticular materials, any surface geometry which did not closely matchthe bearing surface of the tibia or femur, could cause premature wear ofthe remaining cartilage due to asymmetric loading.

[0015] Newer materials technologies in development include filling thejoint space by injecting polyurethane (U.S. Pat. No. 5,795,353) into thejoint and anchoring it with holes drilled into the tibial plateau.Others include a series of polymeric materials such as PVA Hydrogels ina titanium mesh as described by Chang et al, “Historical Comparison ofTibial Articular Surfaces Against Rigid Materials And ArtificialArticular Cartilage,” Journal of Biomedical Material Research, 37,51-59, 1997, biodegradable anhydride prepolymers that can be crosslinked with irradiation by UV light (U.S. Pat. No. 5,902,599) andin-vivo grown articular chondrocytes in a collagen fiber or otherbio-compatible scaffold (U.S. Pat. No. 5,158,574). Other low surfaceenergy materials, such as low temperature isotropic (LTI) pyroliticcarbon, have been investigated as bearing surfaces as well.

[0016] All of these techniques are limited by one's ability to first ofall fashion these materials in a conformal fashion to replicate theexisting knee geometry, while at the same time, maintaining theirlocation within the joint while further being able to survive themechanical loading conditions of the knee.

[0017] Therefore, what is needed is a uni-compartmental interpositionalspacer which, by effectively replacing worn articular material, restoresnormal joint alignment without requiring any bone resection or any meansof bone fixation and provides an anatomically correct bearing surfacefor the femoral condyle to articulate against.

SUMMARY OF THE INVENTION

[0018] According to one embodiment, an implantable knee prosthesisincludes a body having a substantially elliptical shape in plan and apair of opposed faces. A peripheral edge of variable thickness extendsbetween the faces and includes a first side, a second side opposite thefirst side, a first end and a second end opposite the first end. Thethickness of the peripheral edge at the first side is greater than thethickness of the peripheral edge at the second side, the first end andthe second end.

BRIEF DESCRIPTION OF THE DRAWINGS

[0019]FIG. 1 is a plan view illustrating an embodiment of an implantableknee prosthesis.

[0020]FIG. 2 is a cross-sectional view taken along the line A-A of FIG.1.

[0021]FIG. 3 is a cross-sectional view taken along line B-B of FIG. 1.

[0022]FIGS. 4a-4 e illustrate several views of an embodiment of thedevice.

[0023]FIGS. 5a-5 d illustrate several views of another embodiment of thedevice.

[0024]FIG. 6 illustrates placement of the prosthesis in a knee joint.

DETAILED DESCRIPTION

[0025] The present device is an implantable knee prosthesis in the formof a unicompartmental interpositional spacer which, by effectivelyreplacing worn articular material, restores the normal joint alignmentand provides a congruent bearing surface for the femoral condyle toarticulate against. Further, it essentially eliminates articulationagainst the tibial surface thereby preventing further degradation of thetibial surface. Degeneration of the femoral anatomy is significantlyreduced because the conforming femoral surface of the deviceaccommodates the complex shape of the femoral condyle in extension aswell as in flexion. Insertion of the device is done via a 3 cm to 5 cmmedial parapatella incision after arthroscopic debridement of thefemoral and tibial cartilage and removal of medial meniscus toward therim along the anterior, medial and posterior portions. No bone resectionor mechanical fixation of the device is required. Only osteophytes whichinterfere with the device placement or with proper collateral ligamentalignment are removed. The device is offered in multiple thicknesses inorder to occupy the joint space and tighten the “loose suspenders”problem of the collateral ligaments. By occupying the joint space andretensioning the collateral ligaments, the unicompartmentalinterpositional spacer improves joint stability and restores the limb toa more normal mechanical alignment.

[0026] An implantable knee prosthesis 100 is illustrated in FIG. 1. Ananterior/posterior (A/P) cross-sectional view is taken along sectionline A-A and illustrated in FIG. 2. A medial/lateral (M/L)cross-sectional view is taken along section line B-B and illustrated inFIG. 3. A Coordinate System Origin (CSO) 10 is at the intersection oflines A-A and B-B. Prosthesis 100, FIGS. 1-3, includes a body 102 havinga peripheral edge 112, a first or tibial face 104 and a second orfemoral face 106.

[0027] The current mechanical structure is a compromise between thegeometry of the femoral condyle and the kinematics of the knee.Specifically, the femoral condyle has two major AP radii such that whenthe knee is full extension, one radius position is in contact with thetibial plateau while, during flexion, another portion of the femoralcondyle is in contact with the tibial plateau. Further complicationsarise when it is recognized that the femur rotates with respect to thetibia during flexion, thereby changing the orientation of the femoralanatomy to the tibial plateau. Much study has been dedicated todetermine if any relationship exists in the normal human anatomy thatwould allow one to define the required dimensions of the device forproper fit and function based on a single, easy to establish, measurableanatomic landmark. Based on a study of over 100 MRI's and 75 X-rays ofhuman subjects ranging from 15 to 87 years of age, a relationship wasestablished between the anteroposterior radius of the most distalportion of the femoral condyle and the dimensions which control thegeometric form of the device. The database revealed a range of femoralanteroposterior radii from 32 mm to 48mm. However, it is known that theworldwide range is much larger because of race differences in the humananatomy.

[0028] A preferred method of construction aligns the apex of a femoralradius with the CSO 10. FIG. 1. The apex of a tibial surface is alsogenerally aligned in both the A/P and M/L directions with the CSO 10,but is separated vertically from the CSO 10 to create the partthickness. The substantially oval shape of the peripheral edge 112 isthen located with respect to the CSO 10. In general, the CSO 10 of thedevice is located at the center of the ellipse and a minor axis of theellipse F is related to a major axis D by a ratio ranging from F=0.25Dto 1.5D with a preferred value of=0.64D. Similar ratios can beestablished for all of the controlling dimensions of the part such thatthe shape in plan, i.e., as observed from above or below, femoralsurface geometry, and tibial surface geometry for a normal tibialanatomy can generally be defined by one physical A/P measurement of thepatient's tibial anatomy. The appropriate thickness of the implant canbe determined by measuring the amount of joint space between the femoraland tibial surface when a minor amount of valgus (heels out, knees in)is applied to the knee.

[0029] Referring again to FIGS. 1-3, the preferred relationship betweenfemoral radius RA to other joint dimensions (femoral radius is thedriving radius to all other dimensions) is as follows:

[0030] Medial-lateral radius RB=0.25A to 1.0A

[0031] Curve of anterior half of Femoral Radius RC=0.5A to 2.0A,Posterior half is straight

[0032] Length D=0.6A to 1.4A

[0033] Posterior half E=0.1A to 0.75A

[0034] Width F=0.25A to 1.5A

[0035] Width from part center to medial edge G=0.096A to 0.48A

[0036] Anterior plan radius RH=0.16A to 0.64A

[0037] Posterior plan radius RM=0.16A to 0.64A

[0038] Radius along lateral spine area RP=0.1A to 2.0A

[0039] Width from part center to lateral edge Q=−0.32A to +0.32A

[0040] Location of transition from anterior radius to medial radiusY=−0.32A to +0.32A (a negative value means that a dimension may extendto an opposite side of section line A-A).

[0041] Below are the preferred ratios used to define the shape ofprosthesis 100 in terms of the dimension RA, i.e. the femoral radius ofprosthesis 100.

[0042] P=0.238A

[0043] E=0.5A

[0044] F=0.64A

[0045] H=0.32A

[0046] M=0.384A

[0047] G=0.352A

[0048] Q=0.1056A

[0049] Y=0.1152A

[0050] B=0.68A

[0051] D=RA

[0052] RC=RA

[0053] The actual shape of the present device may be tailored to theindividual. Individuals with high varus or valgus deformation due towear, degeneration, or disease, may require a device which is ofconsiderably greater thickness over the portions where wear is mostadvanced. For example, many patients who suffer from this early stage ofdegenerative arthritis will have large areas of eburnated bone along themedial edge of the tibial plateau and femoral condyle but havesignificant cartilage remaining along the tibial spine. In theseinstances the tibial surface of the implant may be thicker along themedial edge to accommodate the defects on the tibial plateau and enhancethe stability of the device. An implant made to these specificationswould be more wedge-shaped when viewed in a frontal plane, with themedial side of the implant being the larger side of the wedge. Thiswedge could be oriented in any direction to accommodate the specificlocation of significant cartilage loss for a given patient.

[0054] Alternatively, the cartilage loss can be concentrated in thecentral load bearing portion of the femoral condyle. This conditionresults in a femoral condyle which is essentially flat when the knee isin terminal extension. In order to bridge the flattened area of thefemoral condyle, the femoral surface of a specific implant size can beenlarged while maintaining the geometric area of the tibial surface.This modification of the implant would prevent overhang of the tibialsurface beyond the border of the tibial plateau while providing a largersurface area to distribute the contact loads at the femoral surface. Inother instances, it may be preferable to decrease the femoral surfacearea for a given implant size.

[0055] Degeneration in the medial compartment will cause the femoralcondyle to shift towards the medial edge of the tibia such that thecenter of the femur is no longer directly above the center of the tibia.In some patients it may be desirable to offset the femoral surface ofthe implant laterally with respect to the tibial geometry to put thefemur back in a more normal alignment. Other degenerative conditions canexist which could be accommodated by offsetting and/or rotating thefemoral geometry in a variety of directions with respect to the tibialsurface.

[0056] In youthful patients, where trauma-induced damage rather thansevere wear or degeneration has occurred, differences in devicethickness will be more moderate. In general, the device is kidney-shapedwhen viewed in plan, and has a negative meniscus shape when viewed fromthe side, i.e.; the thickness along the periphery of the device beinggreater than the thickness along the center of the device. Thekidney-shape in plan may be described generally as elliptical, the shaperesembling a distorted ellipse.

[0057] One skilled in the art can approximate the generally ellipticalshape with a combination of straight lines and radial blends. Therefore,the term “substantially elliptical” is intended to include allconstruction methods which yield a planar shape which is longer in onedirection than the transverse direction, and has rounded corners.

[0058] The present invention is intended to fill in the space thatresults from cartilage loss on both the femoral condyle and tibialplateau. The thickness of the implant at the CSO should be approximatelyequal to the combined amount of cartilage loss from the two boneysurfaces. When an implant of proper thickness is inserted between thefemur and the tibia, the limb is restored to its proper anatomicalignment and ligament structures around the knee are retensioned.

[0059] As previously described, the implant is thicker at the posterioredge than at the CSO because it replicates the shape of the intactmeniscus. In order for the implant to center itself on the surface ofthe tibia, the thick posterior edge of the device must be forced beyondthe most distal aspect of the femur where the space between the femurand tibia is the smallest. Insertion of the implant is accomplished byforcing the medial compartment joint space open while lifting the tibiaover the posterior edge of the implant. To make the insertion of theimplant easier, the implant could be separated into a femoral portionand a tibial portion. The femoral portion could be positioned againstthe distal femur and then the tibial portion could be inserted into theknee separately. The two portions could engage each other along a linearor curved runner to insure proper orientation between the articulationsurfaces. The runner would preferably provide a slidable connection,such as a dovetail, between the two portions that would prevent themfrom separating.

[0060] For example, in the embodiments of FIGS. 4a-4 d, an implantableknee prosthesis is generally designated 400 and includes a body 402having a substantially elliptical shape in plan, and a pair of opposedfaces. A first or tibial face 404 includes a convex surface 406. Asecond or femoral face 408 includes a concave surface 410. Morespecifically, first face 404 and second face 408 are substantiallykidney shaped.

[0061] A peripheral edge 412 of variable thickness extends between thefirst face 404 and the second face 408. The peripheral edge 412 includesa first or medial side M, a second or lateral side L, opposite the firstside M, a first or anterior end A, and a second or posterior end P,opposite the first end A.

[0062] The first side M of the peripheral edge 412 is of a firstthickness T1. The second side L, the first end A, and the second end P,each have a second thickness T2, which is less than T1. The differencebetween first thickness T1 and second thickness T2 may be accomplished,for example, by providing the first face 404 with a first portion A anda second portion B. The second portion B extends at an angle α relativeto the first portion A. The additional thickness of T2 is thus mediallyshifted on the tibial face 404 to accommodate bone loss.

[0063] Prosthesis 400 as viewed in FIG. 4e, is similar to prosthesis100, FIG. 1, in that a dimension D, in a range of from about 0.6A toabout 1.4A, is defined by the first end A and the second end P. Anotherdimension F is defined by the first side M and the second side L. It hasbeen found that a suitable size for body 402 is defined by the dimensionF being from about 0.25A to about 1.5A of the dimension D. Also adimension E extends from the CSO 10 of the body 402 to the first end A.It has also been found that a suitable size for body 402 is also definedby the dimension E being from about 0.1 to about 0.75A of the dimensionD. Further, a dimension G extends substantially from the CSO 10 of body402 to the first side M. It has further been found that a suitable sizefor body 402 is further defined by the dimension G being from about0.096A to about 0.48A of the dimension F.

[0064] In another embodiment, FIGS. 5a-5 d disclose an implantable kneeprosthesis generally designated 500 including a body 502 having asubstantially elliptical shape in plan, and a pair of opposed faces. Afirst or tibial face 504 includes a convex surface 506. A second orfemoral face 508 includes a concave surface 510. More specifically,first face 504 and second face 508 are substantially kidney shaped.

[0065] A peripheral edge 512 of variable thickness extends between thefirst face 504 and the second face 508. The peripheral edge 512 includesa first or medial side M, a second or lateral side L. opposite the firstside M, a first or anterior end A, and a second or posterior end P,opposite the first end A.

[0066] The first side M of the peripheral edge 512 is of a firstthickness T1. The second side L, the first end A and the second end P,each have second thickness T2, which is less than T1. The differencebetween the first thickness T1 and the second thickness T2 may beaccomplished, for example by providing a first body piece 522 attachedto a second body piece 524. The first body piece 522 includes the firstface 504 and the second body piece 524 includes the second face 508. Thefirst face 504 is at an angle a relative to the second face 508.

[0067] The first body piece 522 may also have a keyed slidinginterconnection with the second body piece 524. For example, a surface526 of the first body piece 522 may include a keyway 528, and a surface530 of the second body piece 524 may include a key 532 for slidingengagement with keyway 528 at an interface of the respective surfaces526 and 530. Thus, the additional thickness T2 is medially shifted onthe tibial face 504 to accommodate bone loss.

[0068] In the embodiments of FIGS. 4a-4 d and 5 a-5 d, the convexsurface of the first face includes a contour angle (discussed above)which is substantially the same as an associated contour angle of atibial plateau. The concave surface of the second face includes acontour angle (discussed above) which is substantially the same as anassociated femoral condyle. In this manner, the first and second facesare contoured such that the prosthesis is self-centering between atibial plateau and a femoral condyle as discussed above.

[0069] An exemplary use of, for example, prosthesis 400 is illustratedin FIG. 6. Prosthesis 400 is positioned in a knee joint 600 between afemur 602, including the femoral condyles 604, and a tibia 606 includingthe tibial plateau 608. The femur 602 and tibia 606 includeinterconnecting collateral ligaments 610. The device 400 illustrates theposition of the posterior end P, the anterior end A, the medial side Mand the lateral side L when the device 400 is inserted in the knee joint600.

[0070] The prosthetic device of the subject invention is aunicompartmental device suitable for minimally invasive, surgicalimplantation without requiring bone resection. The device is positionedwithin a compartment in which a portion of the natural meniscus isordinarily located. The natural meniscus may be maintained in positionor may be wholly or partially removed, depending upon its condition.Under ordinary circumstances, pieces of the natural meniscus which havebeen torn away are removed, and damaged areas may be trimmed asnecessary. In somewhat rarer instances, the entire portion of themeniscus residing in the meniscal cavity may be removed. Actually, asdescribed hereinafter, the shape of the present device is not the sameas the natural meniscus, and in most cases, will not entirely replacethe meniscus.

[0071] By the term “unicompartmental” is meant that each device issuitable for implantation into but one compartment defined by the spacebetween a femoral condyle and its associated tibial plateau. In otherwords, the present device is not a “bicompartmental” device which, inone rigid device, could be inserted into both of the femoralcondyle/tibial plateau compartments. In many, if not most cases, adevice will be inserted into one compartment only, generally the medialcompartment, as the meniscus and associated articular surfaces in thesecompartments (left knee medial and right knee medial compartments) aremost subject to wear and damage. However, it is possible to insert twoseparate devices into the medial and lateral compartments of the sameknee, or to use two such devices that are mechanically but non-rigidlylinked.

[0072] The present device is translatable but self-centering. By“translatable” is meant that during natural articulation of the kneejoint, the device is allowed to move, or change its position. Thus, thepresent device is devoid of means of physical attachment which limit itsmovement (for example, screws, mating ridges and depressions, porousareas to accommodate tissue regrowth, and the like).

[0073] The term “self-centering” means that upon translation from afirst position to a second position during knee articulation, the devicewill return to substantially its original position as the articulationof the knee joint is reversed and the original knee position is reached.Thus, the device will not progressively “creep” toward one side of thecompartment in which it is located. Rather, the angle of attack of thefemoral condyle and/or tibial plateau bearing surfaces against thedevice will ensure that the device reversibly translates duringarticulation, maintaining the device, on average, in the same locationfor any given degree of knee articulation. The centered, rest position,of the implant is usually determined when the knee is in extension andthere is maximum contact between the femoral condyle and the device.This ability of the device to “self-center” can be compromised byinadequate tension of either one or both of the cruciate ligaments.Unbalanced or excessive cruciate ligament tension can possibly cause thedevice to locate itself in a more anterior position on the tibia, whichis less desirable.

[0074] Contrary to most devices which are composed of soft, compliantmaterial designed to assume the function of the natural meniscus whichthey replace, the present device is composed of relatively hard,relatively high modulus material. Suitable materials are, for example,steel, ceramics, and reinforced and nonreinforced thermoset orthermoplastic polymers. The device need not be made of a singlematerial, but composite structures of steel/thermoplastic,steel/ceramic, ceramic/polymer, etc., may be used. Alternatively,composites of the above materials with biologically active surfaces orcomponents may be used. Biologically active components include surfacesthat may contain pharmaceutical agents to stimulate cartilage growth orretard cartilage degeneration that may be delivered at once or in atimed-release manner.

[0075] Generally, portions of the device expected to have the most weardue to either greater movement relative to the mating surface (i.e.,relative to the femoral condyle or tibial plateau) or high stress, maybe made of stronger, more abrasion resistant material than the remainderof the device when composite structures are used. This method may beideal for use in conjunction with cultured chondrocyte implantation(cartilage cells used as seeds) or osteochondral transplantation.Moreover, when the locus of damage to the articular cartilage or to aportion of the bone structure are known, the relatively constant radiusof the surface of the present device will bridge the defective areas atthese loci, thus redistributing load to healthy tissue and allowinginflamed, diseased, or other damaged areas to regenerate.

[0076] For example, a portion of the femoral condyle, tibial plateau,articular cartilage, etc., may have been damaged or may experiencetissue degeneration. The continued load experienced at such points andthe wear experienced as the knee flexes will substantially hinder theregeneration of healthy tissue. If suitable biologically activematerials, chondrocytes, etc. are applied to the damaged or degeneratedsurface to assist in tissue regeneration, these will, under ordinarycircumstances, be rapidly dissipated. If a flexible, cushiony materialis inserted within the knee compartment, the damaged area will stillexperience intimate contact with the damaged area under static loads,and will also experience continued wear and abrasion under non-staticconditions. Under such circumstances, active substances will be rapidlydissipated. However, more importantly, newly regenerated articularcartilage not having the necessary density or cohesiveness to withstandwear, will be rapidly eroded away.

[0077] The present device may be supplied with a contoured surface whichdistributes the loads evenly over regions of healthy articular cartilagewhile bridging areas where articular cartilage degeneration or damagehas occurred. Active substances may be applied at once or in atimed-release manner to the degenerated or damaged articular cartilagesurface by means of, or in conjunction with, the present device. Becausethe recess or shape of the device protects the damaged area from loadsand wear, tissue regeneration may occur without disturbance. Theregenerating tissue will have time to mature and crossline into a fullydeveloped matrix. Moreover, as regeneration proceeds, the regeneratingtissue will assume a shape dictated by the shape of the device. Growthunder these circumstances has the greatest potential for dense, orderedcartilage most closely replicating the original surface.

[0078] The hardness of the present device is preferably higher thanShore 60 D. The Shore hardness may range from that common forengineering grade plastics to hardened steel and titanium, andpreferably on the portion of the Rockwell hardness scale typical ofsteels, hard plastics and ceramic materials. From the high hardnessdesired of the device, it is readily apparent that the device functionsin a manner completely different from those of the prior art. Thepurpose of the device of the subject invention is to achieve a span-likeeffect to bridge the defective areas. However, in a composite variation,any single component (like a bioactive material component) may be softerthan the supporting material. Rather than deforming to distribute a loadrelatively equally on the mating surfaces, the device of the presentinvention functions as a rigid, substantially non-deforming,self-centering bearing, which does not necessarily spread the loaduniformly, but rather may concentrate the load upon desired points,spanning areas of imperfection. If a soft and/or low modulus elastomeror thermoplastic is used for the entire device, not only is the load notconcentrated on healthy tissue, but damaged areas will also be subjectedto loading, thereby decreasing the opportunity for the body's naturalregenerative capability to function.

[0079] The high modulus of the present device thus allows for theprovision of recessed or non-contacting areas of the device to encouragearticular cartilage regeneration. In softer, lower modulus materials,the naturally occurring loads, which may exceed 1000 lbs/in², in certaincases, will cause the softer devices to deform and allow ordinarilynon-contracting areas to contact bone or cartilage for which contact isnot desired. A flexural modulus of elasticity for load bearing portionsof the present device should therefore be preferably greater than 2×10⁵psi, and more preferably greater than 3×10⁶ psi. Portions of the devicenot exposed to the highest loads may be made of lower modulus materials,which may be softer as well (e.g., in a non-limiting sense, nylon,polyurethane, polypropylene, polyester, and the like, optionally fiberreinforced).

[0080] As indicated previously, the device of the subject invention maybe manufactured so as to substantially contain or have depositedthereon, a biologically or pharmaceutically active material. This isparticularly suitable when the device bridges a defective area of boneor articular cartilage. In such cases, the device may be provided with acoating containing a biologically or pharmaceutically active material,for example one that promotes tissue regrowth or one that decreasesinflammation. Such materials may also, and more preferably, be containedin a portion of the meniscal device. The portion may be filled withmedication, or may be filled with a gel, paste, or soft polymer materialthat releases medication over a period of time. Preferably, thismedically active portion does not actually contact, or minimallycontacts, the damaged tissue. This freedom from contact is made possibleby the surrounding bearing surfaces. Coatings may also be of a gel,paste, or polymer containing time-release medicaments. Biologically andpharmaceutically active materials are identified subsequently herein as“active materials.”

[0081] The edges of the device are rounded rather than presenting thesharp corners of the devices of U.S. Pat. No. 5,158,574. This roundedperiphery is necessary due to the fact that the device will be allowedto move within the cavity. Movement of a device having a periphery withsharp comers would result in the potential for severe damage to thesurrounding tissue and articular surfaces, in addition to causing pain.A “depression” in the elliptical shape on the part of the device whichwill be proximate to the tibial spine will vary from patient to patient.It is possible due to the great range of variability of human anatomythat this depression might be absent in devices for some patients.However, the overall shape in plan is substantially ellipticalregardless.

[0082] The axis of rotation of the tibia on the femur is 90 degrees tothe path of the tibial plateau against the femoral condyle. The twotibial plateaus (medial and lateral) are not in the same plane with eachother but do act in a relatively constant radius to its respectivefemoral condyle. In other words, although the symmetry of the device'sfemoral side may be matched with the femoral condyle while the leg is infull extension, the rotation of the tibial plateau against the femoralcondyle is along a constant axis of rotation (90 degrees to the axis ofrotation), thus the angularity of the axis of symmetry of the femoralcondyle relative to the axis of symmetry of the tibial plateau is notparallel but at some acute angle. Also, the axis of symmetry of thetibial plateau is not parallel to the path of rotation of the tibiarelative to the femur but also at some mildly acute angle. Thus, thetrue orientation of the device, regardless of the relative orientationsof symmetry of the tibial side to the femoral side is 90 degrees to thetrue axis of rotation as described in Hollister et al., “The Axes ofRotation of the Knee”, Clin. Orthopaedics and Rel. Res., 290 pp.259-268, J. B. Lippincott Co., 1993, herein incorporated by reference.Any localized positions of higher loads are self-limiting due to theability of the device to translate both rotationally and laterally whichmimics the true motion of the natural meniscus as described byHollister.

[0083] During the load bearing portion of the gait cycle, or stancephase, flexion at the knee does not typically exceed 35°. Thus, thehighest compressive loads in the knee occur with the knee substantiallyextended. The outer contours of the device are therefore designed tosubstantially mate with the corresponding tibial and femoral surfaceswhen the knee is in full extension so that the high compressive loadscan be distributed over large surface areas. The contact areas betweenthe femoral condyle and the femoral surface of the device, and thetibial plateau and the tibial surface of the device are substantiallyequivalent during extension. However, because the contour of the femoralsurface is more concave, the femoral condyle determines the position ofthe device on the surface of the tibial plateau in extension.

[0084] As the knee is flexed, the mating along the tibial surface issubstantially maintained. However, the contoured mating surfaces of thefemoral condyle and femoral surfaces of the present device can becomeincreasingly dissimilar when the joint articulates. As the knee isflexed, there is a relative external rotation and posterior translationof the femur with respect to the tibia. Thus, the contour angle of thefemur becomes more in-line with the contour angle of the tibia inflexion. This can cause relative lateral or rotational movement, in thetibial plane, between the femoral condyle and the femoral surface of thedevice. The forces generated by the increasingly different geometrycreates a rotational moment, in the tibial plane, which is resistedalong the mating tibial surfaces and which also results in a restoringforce tending to correctly locate the device along the femoral condyle.Thus, the device is self-centering to the femoral condyle, in part, as aresult of the conformity between the femoral condyle and the femoralsurface of the device.

[0085] By changing the femoral surface of the implant, it is possible toreduce the rotational moment induced during flexion by the mismatchbetween the femoral surface of the implant and the femoral condyle. Apreferred method to accommodate this motion is to have a less acutealignment between the femoral and tibial axes of symmetry posterior tothe A/P midline, thereby reducing the mismatch between the two axes inflexion. This angle is preferably 0° and can range from +/−10°. Anteriorto the midline, the femoral contour is bent around a radius RC that istangent to the posterior section of the sweep plane at the most distalpoint of the femoral A/P radius RA. This femoral surface geometry isessentially a compromise between the different extension and flexionalignments of the femoral and tibial axes of symmetry.

[0086] Because the device has no physical method of attachment, thecombination of the slightly concave tibial surface and the convexfemoral surface serves to locate the device though all ranges of motionprovided that the collateral ligaments are in proper tension. If toothin, a device could be ejected from the knee compartment. By the verynature of the ability to adjust for the lost articular material throughthe thickness of the device, the thickness adjustment substantiallyeliminates the need for a functional meniscus as a bearing surface in aseverely (Grade III or IV) degenerated knee. In these instances, thefemoral surface of the device resides significantly above the meniscaledge, and the meniscus is completely unloaded.

[0087] The device also increases the translational stability of theknee. The conforming shape of the femoral surface limits excessiveanterior to posterior translation of the femur. As a result, this devicepossibly eliminates the need for ACL reconstruction in the olderpatient.

[0088] Generally speaking, each knee presents a different geometry ofthc respective femoral condyles and tibial plateaus. Even with respectto the right and left knees of a single individual, although bilateralsymmetry dictates that the left and right knee components should bemirror images, this is often only an approximation. Thus, the shape ofthe affected femoral condyle and tibial plateau (while discussed hereinin the singular, more than one pair of condyle(s)/plateau(s) may beinvolved), will have to be ascertained to determine the correct geometryof the device for a given patient.

[0089] To implant a device that possesses the characteristics requiredby the subject invention, the patient's knee joint may be examined by anon-invasive imaging procedure capable of generating sufficientinformation such that one appropriately sized and shaped device may beselected. While a variety of non-invasive imaging devices may besuitable, for example X-ray devices and the like, it is preferable thatinformation as to the size and shape of the device be provided bymagnetic resonance imaging (MRI).

[0090] Two methods of non-invasive imaging for selection of a suitableprosthesis are preferred. In the first method, MRI or other non-invasiveimaging scans, optionally coupled with exterior measurements of thedimensions of the relevant tibial and femoral portions including thesurface of the particular cartilage of the tibia and femur, may be usedto establish a library of prostheses whose size and geometry differaccording to the age and size of the patient, the patient's geneticmake-up, and the like. A limited number of “standard” devices are thenmade to meet the requirements of a generic population of patients.

[0091] In this first method, a non-invasive imaging scan, such as X-rayor MRI, together with knowledge of the patient's genetic make-up,general body type, extent of the disease, degeneration, or trauma andthe like, will enable the surgeon to select a device of the correct sizeand shape from the library for the patient. The device is thenintroduced by arthroscopically assisted implantation, generally limitedto extensive clean-up of existing damaged tissue, e.g., torn orparticulate natural meniscus damage. It may also be used in conjunctionwith tibial osteotomy or articular surfacing procedure such as cartilagetransplantations or abrasion anthroplasty. Following insertion of thedevice, X-ray, Fluoroscopy, or MRI may be used to assess the correctpositioning of the device both introperatively as well aspostoperatively. Because the surgical procedures used are not severe,and also not irreversible, an unsuitable device may be readily removedand replaced, either with a different device from a device library, orby a custom device.

[0092] In a second method, each patient receives one or more devicesthat are custom tailored for the individual by producing a contour plotof the femoral and tibial mating surfaces and the size of the meniscalcavity. Such a contour plot may be constructed from imaging data, i.e.MRI data, by a suitable computer program. From the contour plot, thecorrect surface geometry of the device is determined from the shape ofthe respective tibial plateau and femoral condyle and the orientationbetween the two surfaces in extension. In general, the shapes justmentioned also include the articular cartilage, which, in general, ismaintained substantially intact.

[0093] In accordance with this invention it has been discovered that theamount of varus deformity is the primary, non-invasive method fordetermining the necessary device thickness required for properfunctioning of the device. Viewing a weight bearing anteroposteriorX-ray, a cut and paste of a line drawn through the femoral condyles andrepositioned to put them once again parallel to the tibial plateaus willyield a measurement for the approximate device thickness.

[0094] A further understanding can be obtained by reference to thefollowing specific example that is provided herein for purposes ofillustration only and is not intended to be limiting unless otherwisespecified.

[0095] For Example:

[0096] A 44-year-old male had an 18-degree flexion contracture in hisright knee. The right limb was in 5 degrees of varus alignment and thepatient suffered from significant, debilitating pain. X-rays of theaffected limb showed significant collapse of the medial joint space aswell as significant osteophyte formation along the medial border of thefemoral condyle. Pre-operative templating of the X-ray indicated thatthe right medial condyle had a radius of approximately 46 mm. A libraryof implants was manufactured for this patient based upon thepreoperative radius measurement and the dimensional relationshipsestablished from the X-ray and MRI database. The library includedimplants with a femoral radius measuring 42 mm, 46 mm and 50 mm.Implants of 2 mm, 3 mm and 4 mm thickness were made in each sizecategory. The patient was then scheduled for surgery.

[0097] Arthroscopic evaluation of the joint on the day of surgeryrevealed generalized Grade III chondromalicia of the medial femoralcondyle and tibial plateau with small areas of Grade IV changes.Patellofemoral and lateral joint compartment changes were mild. Anarthroscopic debridement of the joint was completed and the degeneratededge of the meniscus was resected. A small ruler was inserted throughthe anterior arthroscopic portal and the distance from the posterior rimto the anterior rim of the remaining meniscus was recorded as 42 mm. Ashort median parapatellar incision was completed to expose the medialcompartment of the knee. An osteotome and a rongure were used to removethe osteophytes along the medial border of the femoral condyle. Plasticgages representing the different implant thicknesses were then insertedbetween the femur and the tibia to measure the amount of joint spacepresent in the medial compartment. These measurements indicated that a 4mm thick part would be required to occupy the joint space and restoretension to the medial compartment. Several trial implants were insertedinto the joint space and a fluoroscope was used to verify the fit andpositioning of each trial. This final trial reduction confirmed that theappropriate part was a 42 mm long by 4 mm thick implant. The implant wasinserted into the joint. A final check of the implant's stability andfit was performed. Careful attention was paid to the evaluation ofimplant thickness because an inappropriately thick implant could preventthe patient from achieving full extension. After all interoperativechecks were complete the incision was closed.

[0098] Postoperative X-rays revealed a 7-degree correction of the limbalignment. The implant also stabilized the knee. At 10 months offollow-up the patient is pain free and can achieve full knee extension.The patient can also achieve approximately 120 degrees of flexion.

[0099] One preferred surgical procedure which may be used to implantthis device can be described by the following steps:

[0100] 1. Verify preoperative indications:

[0101] a. Varus determination of <5 degrees with erect AP X-ray;

[0102] b. Medial compartment disease only. Some lateral spurs may bepresent; and

[0103] c. Pre-operative sizing via M/L template measurement of A/PX-ray.

[0104] 2. Standard Arthroscopy surgical prep:

[0105] a. Infiltrate knee with Lidocaine/Marcaine and Epinephine.

[0106] 3. Arthroscopy:

[0107] a. Inspect lateral patello-femoral compartments for integrity,some mild arthrosis is acceptable;

[0108] b. Removal of medial meniscus toward the rim along the anterior,medial and posterior portions;

[0109] c. Initial arthroscopic osteophyte removal via ⅛″ osteotome andburr to allow for valgus positioning of the knee;

[0110] d. Complete the removal (to the rim) of the posterior andposterior-lateral meniscus; and

[0111] e. Confirm sizing of the device by measuring distance fromresected posterior meniscus to remaining anterior meniscus.

[0112] 4. Medial parapatellar arthrotomy (mid-patella to tibial jointline).

[0113] 5. Complete removal of visible osteophytes along the medialfemoral condyle.

[0114] 6. Insert thickness gauge and size for implant thickness.

[0115] 7. Insert trial component:

[0116] a. Flex knee to approximately 50+degrees to fully expose thedistal portion of the femoral condyle;

[0117] b. Insert trial component; and

[0118] c. While applying insertion pressure, apply valgus stress to thetibia and “stretch-extend” the tibia over the trial component.

[0119] 8. Check for proper sizing with “true lateral” and A/Pfluoroscope images of the knee while in extension:

[0120] a. Ideally, the device should be within 1 mm of the A/P boundriesof the tibial plateau and superimposed over the medial boundary.

[0121] 9. Remove trial component and flush joint with saline.

[0122] 10. Insert the appropriate implant.

[0123] 11. Confirm proper placement and sizing with fluoroscopic imagesas with trial component.

[0124] 12. Maintain leg in extension and close wound after insertion ofa Hemovac drain.

[0125] 13. Place leg in immobilizer prior to patient transfer.

[0126] Having now fully described the invention, it will be apparent toone of ordinary skill in the art that many changes and modifications canbe made thereto without departing from the spirit or scope of theinvention as set forth herein.

What is claimed is:
 1. An implantable knee prosthesis comprising: a bodyhaving a substantially elliptical shape in plan and a pair of opposedfaces; a peripheral edge of variable thickness extending between thefaces and having a first side, a second side opposite the first side, afirst end and a second end opposite the first end; and the thickness ofthe peripheral edge at the first side being greater than the thicknessof the peripheral edge at the second side, the first end and the secondend.
 2. The prosthesis as defined in claim 1 wherein one of the facesincludes a first portion and a second portion, the second portionextending at an angle with the first portion.
 3. The prosthesis asdefined in claim 1 wherein the body is a one-piece body.
 4. Theprosthesis as defined in claim 1 wherein the body includes a firstpiece, attached to a second piece.
 5. The prosthesis as defined in claim4 wherein the first piece and the second piece are mutually slidablyengagable and separable.
 6. The prosthesis as defined in claim 4 whereinthe first and second pieces are keyed for sliding engagement.
 7. Theprosthesis as defined in claim 4 wherein the first piece includes afirst face and the second piece includes a second face, the second facebeing at an angle with the first face.
 8. The prosthesis as defined inclaim 1 wherein a first dimension D is defined by the first end and thesecond end, and a second dimension F defined by the first side and thesecond side, where the dimension F is from about 0.25 to about 1.5 ofthe dimension D.
 9. The prosthesis as defined in claim 8 wherein one ofthe faces is a femoral face including an anterior to posterior radius Aand the first dimension D, where D is from about 0.6A to about 1.4A. 10.The prosthesis as defined in claim 9 wherein the anterior to posteriorradius A is equal to the first dimension D.
 11. The prosthesis asdefined in claim 9 wherein the second dimension F is 0.64A.
 12. Theprosthesis as defined in claim 9 wherein the femoral face includes amedial to lateral radius B of from about 0.25A to about 1.0A.
 13. Theprosthesis as defined in claim 12 wherein the radius B is 0.68A.
 14. Theprosthesis as defined in claim 9 wherein the femoral face includes ananterior sweep radius C to accommodate relative rotation between femurand a tibia.
 15. The prosthesis as defined in claim 14 wherein C is fromabout 0.5A to about 2.0A.
 16. The prosthesis as defined in claim 15wherein C=A.
 17. A method of providing a knee prosthesis comprising:providing a body having a substantially elliptical shape in plan and apair of opposed faces; extending a peripheral edge of variable thicknessbetween the faces, the peripheral edge having a first side, a secondside opposite the first side, a first end and a second end opposite thefirst end; and providing the thickness of the peripheral edge at thefirst side to be greater than the thickness of the peripheral edge atthe second side, the first end and the second end.
 18. The method asdefined in claim 17 further comprising: removing at least a portion of ameniscus in a knee joint; measuring for a length dimension of theprosthesis; measuring for a thickness dimension of the prosthesis;inserting a trial component into the knee joint; verifying sizing forthe trial component; and inserting the prosthesis.
 19. The method asdefined in claim 18 wherein the prosthesis includes a two-piece bodyhaving a femoral portion and a tibial portion.
 20. The method as definedin claim 19 wherein inserting the prosthesis includes positioning thefemoral portion of the prosthesis in the knee joint and slidinglyengaging the tibial portion of the prosthesis with the femoral portionof the prosthesis.